Provider Demographics
NPI:1407921661
Name:HICKS, DENNIS R (MFT)
Entity Type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:R
Last Name:HICKS
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:938 MARCO PL
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-3920
Mailing Address - Country:US
Mailing Address - Phone:310-823-9556
Mailing Address - Fax:310-306-2296
Practice Address - Street 1:11600 WASHINGTON PL STE 201
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-5068
Practice Address - Country:US
Practice Address - Phone:310-390-8646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT27240106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist